Head injuries cause more deaths and disability than any other nerve condition among those less than 50 years old,. More than 70% of accidents lead to a head injury. 50% of severe head injuries lead to death. (Merck, 2005)

It is the number one cause of death for men and boys less than 35 years of age. (Merck, 2005)

HOW THE BRAIN WORKS

The brain is very complex. It is the master of the body. The body cannot do anything without the brain. A person cannot move their arm or even take a breath if the brain is not working in the correct way.

The brain weighs only about 3 pounds but it has about 100 billion cells! All of these cells are connected to others. The brain sends and gets messages to and from the entire body.

The human body has 2 legs, 2 arms, 2 hands, 2 ears, and 2 eyes, but only one brain. The brain has 2 halves. They are:

The right side or hemisphere and

The left side or hemisphere.

Each side of the brain does a special job. The right side of the brain puts together bits of information. The left side of the brain breaks up large amounts of information into smaller bits.

The right side of the brain:

groups bits of information together.

The left side of the brain:

analyzes things;

breaks information apart into small pieces;

lets us form words.

The right side of the brain will be hurt when a person has a head injury on the right side of the head. The person may not be able to put bits of information together.

The left side of the brain will be hurt when a person has a head injury on the left side of the head. The person may not be able to speak or break information down into small bits. These people can be more depressed than those who have damage to the right side of the brain.

All the information that comes into one side of the brain gets processed on the other side of the brain because the brains "wires" are crossed at the base of the brain.

For example, the back of the brain processes what we see. Both the right and the left side of the back of the brain work on vision. One half goes to the right side of the back of the brain. The left side of the brain then processes it. The other half of what we see goes to the left side of the brain in the back. processed by the right side of the brain.

RIGHT HANDED OR LEFT HANDED?

95% of people are right-handed. The left side of their brains are dominant or stronger. The right side of the brain is stronger for people that are left handed.

HOW WE SEE

The back part of the brain works to let the person see things. The person may not be able to see if this part of the brain is hurt. As said before, one half of what we see goes to the right side of the back part of the brain and the other half goes to the left side of the back of the brain. The left side of the brain processes what goes to the right side. The right side of the brain takes care of the vision that went to the left side of the back part of the brain. The reason for this right-left and right-left switch is because the of the crossing of the pathways in the brain.

MOVEMENT

Movement is controlled by a long, narrow area of the brain that goes from the top of the head and down to the area where the right and left ears are. If you injury the left side of the brain in this motor area, you will not be able to move the right side of the body. You will not be able to move the left side of the body if you injure the motor area on the right side of the brain.

HEARING, READING AND UNDERSTANDING

The right and left temporal lobes of the brain are found at the sides of the head near the top.

Some areas of the temporal lobe work with simple sounds and hearing. Other areas work with sounds that are more complex.

The right temporal lobe helps us with music and noises. The left temporal lobe helps us with speaking and language. This side is more important for everyday things than the right musical side.

Reading is done in the area of the brain where the seeing and the hearing areas are close to each other.

FEELING: THE SENSE OF TOUCH

Information is sent to the right side of the brain when you feel something with your left hand and it is sent to the left side of the brain when you touch and feel something with you right hand.

The area that handles the sense of touch is next to the area that controls movement. People that have had a head injury in this area may have a problem with both touch and movement.

THE FRONT PART OF THE BRAIN: THE FRONTAL LOBE

The most complex part of the brain is the frontal lobe. It is also the largest.

The frontal lobe is in the front part of the skull under the forehead. It helps us to think and it also controls our emotions, like sadness, and happiness. At times people cannot control their emotions when they have had an injury to this part of the brain. Their anger and other emotions are not kept in check. They may lose control.

People that have an injury in this area may also not be able to:

think,

do everyday things, like dressing them self.

HEAD INJURIES

Head injuries can lead to brain injuries. Head injury can happen when the bones of the skull are broken, when the bones of the skull poke through the brain, and when the brain moves back and forth in the skull causing bruises, bleeding and swelling. Every area of the brain can get damage with a head injury depending on where the trauma has happened.

Both the front and the back of the brain can be injured when a person is in a car accident and they slam the front of their head on the dashboard and then jerk back into the seat.

Nerves, the coating of the brain (meninges), and the blood vessels can be damaged with a head injury. This can lead to bruises, bleeding and swelling. Because the brain cannot swell like the skin on an arm or leg can, brain swelling can lead to its getting pushed through the only hole of the bony skull which is at the base of the head. The person will stop breathing and die when this happens. Holes are drilled in the head to release the pressure from this swelling to prevent this kind of death.

KINDS OF HEAD INJURIES

Concussion

This kind of head injury can lead to a temporary loss of:

memory and

awareness.

The person may:

get dizzy,

have a headache,

not be able to concentrate on things,

forget things, and

get depressed and anxious. (Merck, 2005)

Contusions and lacerations

These injuries are very serious. These problems can occur:

paralysis on one side of the body (hemiplegia)

swelling of the brain

rigid arms and extended legs

a clenched jaw and extended arms and legs

big pupils in the eye(s) that do not react to light

slow respiratory rate

high blood pressure

fast pulse

coma

death

Complete and permanent paralysis (quadriplegia) happens when the spine in the neck also happens with the head injury. (Merck, 2005)

Acute subdural hematoma

This injury is seen right after an accident. It involves the seeping of blood in the layers of the brain. Most brain injury deaths happen with this kind of brain injury. Surgery can be done to remove this hematoma but the death rate is still high.

It can lead to:

brain swelling,

rigid arms and extended legs,

a clenched jaw and extended arms and legs,

pupils that are fixed or dilated,

hyper-active reflexes,

spasticity (hemiplegia or quadriplegia),

breathing distress,

coma and

death. (Merck, 2005)

Chronic subdural hematomas

This kind of injury may not appear until a couple of weeks after an accident. It becomes known when the person:

has a daily headache,

is very sleepy,

is confused, and/or

starts hemiparesis. (Merck, 2005)

Epidural hematomas

This injury also involves the seeping of blood in the layers of the brain but the layers are different than those injured with a subdural hematoma. This seeping is between the bony skull and the first layer of the brain. The signs usually happen within a couple of hours after the trauma.

headache,

loss of consciousness,

poor bodily movement, and/or

changes in the pupil.

The brain will shift and the brain will swell if it is not removed with surgery. Coma and death can happen if it is not taken out. (Merck, 2005)

Seizures after an accident

They can start as late as several years after an accident. About 10% of closed head injuries and about 40% of broken skull injuries have seizures after a bad accident. (Merck, 2005)

A persistent (chronic) vegetative state (PVS)

PVS when the front of the brain, which helps us to think, is injured. This state can last for many years. This person needs complete care. They are not able to do anything on their own. (Merck, 2005)

CARING FOR PEOPLE WITH BRAIN INJURIES

Some people have problems for only a short time after the brain injury. Others have problems for the rest of their life.

Some of the problems that a person may have are:

memory problems and confusion,

poor cognition,

behavior problems,

blindness,

not able to speak,

paralysis, and

headaches.

Caring for the Person With Memory Problems and Confusion

SAFETY is the #1 need for people with confusion and a memory problem. Do these things to keep the person safe.

Keep the patient care area safe. Keep the patient's room and the patient care area safe and clean. Take away all clutter and dangerous chemicals, like medicines and cleaning liquids. Use non-skid slippers and shoes for those at high risk for falls.

Respond to the person's calls for help right away. Do not delay.

Check the person's identity before you do any care. This will prevent mistakes.

Keep the patient care area well lit.

Other things that you should do for confused patients and those with memory problems are below.

Keep the noise and activity level low.

Use large clocks, calendars and other things to orient the patient.

Remind the person about the date, time of day and where they are.

Give the person as many reminders as they need.

Be patient with the person.

Spend time with the patient.

Caring for the Person With Impaired Cognition and Communication Problems

A cognitive impairment is a loss that makes it hard for the person to learn, remember and communicate with another person. People with these problems can learn but they can not learn at the same rate as other people. You must:

spend time with the person,

keep it as simple as possible so the person is able to understand what you are trying to teach them,

speak in short sentences,

spread the learning out over a period of time, and

repeat things as often as they need you to.

The person who has a problem with communication may not be able to send a message to others. They may also not be able to get a message from another person.

You must use simple, plain words that a person can understand when you communicate. Do not use words like "hospital", "NPO", "ambulate" or "void" if the person does not know what these special healthcare words mean. You should say, "You can not eat or drink anything after 12 midnight", instead of saying "NPO". You may want to ask the person if they "would like to walk", instead of asking them if they "would like to ambulate". Also, use the word "urinate" or show the male patient the urinal, instead of using the word "void" unless the person understands that word.

Some of the other things that you should do to help when you communicate with the person are:

Include the family and friends in the communication when a person is not able to understand what you are trying to say.

Ask the family and friends how the person can be helped to communicate with you.

Speak in a plain way, using words that are simple. For example, instead of asking if the person is hungry, ask, "Would you like to eat some eggs?"

Talk to the person in a place that is quiet and that does NOT have a lot of distractions. Turn off the radio and TV while you are talking to the person, after you ask them if you can.

Make sure that the person can see you. Turn on the lights if the room is too dark.

Keep the message as short and simple as you can. Many people do best with short talks rather than long ones with a lot of information at one time. It is better to talk for a couple of short sessions, rather than one or two long ones.

Discuss one thing at a time.

Repeat the message as often as needed.

Ask the person one question at a time and listen to or observe for the answer.

Draw pictures or write things down for the person if this helps them understand what you are trying to say.

Let the patient draw a picture or write things down for you if this makes it easier for them to tell you what they want or need.

Ask "yes" and "no" questions. For example, if you want to know if a patient wants to eat fruit, ask "Do you want an apple or a pear?", instead of "Do you want to eat a piece of fruit?"

Use real objects whenever you can. For example, show the person the real object, like an apple, if you are asking the patient if they would like to eat it.

Speak slowly and in a clear way.

Talk in a low pitch, not a high pitched voice.

Face the person that you are talking to.

Make eye contact with the person.

Listen to the person.

Look at the person's face. Is the person trying to tell you something? Do they look like they are in pain? Are they holding a part of their body, like their hand or their head? Do they look sad? Do they look angry?

If a person uses a hearing aid or eyeglasses, make sure that they are on.

Always show respect and caring.

Communicate with touch and a calm voice when you want to tell a person that you care and they do not understand the spoken word.

Take our course, "Communication With the Cognitively Impaired" to learn more about communication with patients who have a problem with cognition.

Caring for the Person With Behavior Problems

The best way to manage poor behavior is to prevent it. The best way to manage it is to stop it before it starts. The prevention of poor behavior needs the help of the whole team, including nursing assistants and personal care aides.

PREVENT poor behaviors.

Know your patients and residents.

Know what kinds of things lead to poor behavior. Know the things that help your patient to behave correctly. For example, give the patient a bath in the morning if they are less confused and agitated in the morning. A bath during the afternoon or evening may make this patient angry and resist care completely.

Poor behavior often happens while care is being given to a patient or resident. Try to calm a patient during care. Keep things the same and keep things simple to prevent poor behavior. Know the best routine for the person and stick to it.

Know what triggers poor behavior and try to keep the person from these triggers.

Get rid of all physical, emotional, environmental, communication and care triggers. Meet the person's needs so they do NOT react with disturbed behavior.

Give simple instructions and repeat instructions if needed.

Listen to the patient or resident.

Many patients and residents will act out with poor behavior when they can't make their needs known. Spend time with your patient. Let them ask you questions. Help them tell you about their feelings. Help them tell you what they want. Use pictures if needed.

Repeat back to them what you think they said or wanted to make sure that you have really heard and understood them. Be clear and calm when communicating with these patients.

Observe your patients and how they act with others.

If another easily angers a patient, encourage both patients to go to a different place for an activity or event.

Approach a very confused patient from the side and speak face to face.

Keep noise down. Make sure that there is enough light. Keep schedules and routines the same for people who act out when things are changed.

Limit choices if needed. Some patients and residents get nervous and frustrated if they have too many choices. Encourage patients and residents to go to well supervised and structured activities if they are at risk for poor behavior when things are not structured.

Keep your attention on the person and not the task.

It is the person and how they are feeling that is important. If a person gets angry during an activity of daily living, break the task down into small parts. Encourage the person to be as independent as possible. Praise the person for their self care efforts.

Provide activities that meet the patients' and residents' needs and prevents poor behaviors.

Clocks and a large calendar or poster with the day of the week, the date, the season and the day's weather often help to orient people to time and current reality. Other socialization and activity groups, like reality orientation groups, holiday parties and reminiscence groups are often helpful.

Relieve stress.

Promote relaxation and other things that lower stress. Pet therapy, music therapy and socialization or exercise groups can lower stress.

Report all patient changes to the nurse in charge.

If a patient condition or behavior changes they may be at risk for acting out behaviors. Report all patient changes.

Be a team member.

Follow the patient's behavior management plan of care. Everyone on the team must be consistent. They must all say and do the same things with the patient.

MANAGE disruptive, unacceptable or dangerous behaviors when they occur:

Stay calm, speak softly and show respect. If inappropriate, dangerous or disruptive behavior occurs, speak to the patient(s) calmly, slowly and with respect. Have them sit to chat. Sit next to them.

Stop the task you are doing.

Call for help if you need it.

Protect all the residents from injury. Stay far enough away from a person so that they can't hit you. Try to sit the person down. Put a pillow on your chest if a person is trying to punch you in the chest. Do NOT fight back. Do NOT pull away if you are grabbed. Stay calm and talk with the person. Remove the person(s) from harm if your words and instructions do not stop the dangerous behavior.

Meet patient needs. If a person is making noise, find out if they are hungry, thirsty, wet, dirty, in pain, too hot, too cold or tired. Meet these needs. Feed the person that is hungry. Give water to the person who is thirsty, etc.

Report all disturbed behavior.

What triggered the behavior? What happened? When time was it? Where did it happen? How long did the poor behavior continue? Was the behavior mild, moderate or very severe? Who else was involved? What did you do to stop the behavior? Did it work?

Caring for the Person With Blindness

Give the person their eyeglasses if they have them. If the person is completely blind they may have a walking stick or a seeing eye dog to help them get around and live as normal a life as they can.

Blind people can also get help with things like a special telephone and reading material in Braille, a raised alphabet that the person can feel.

Caring for the Person That Is Not Able to Speak

Speech therapy helps many people. Also there are things like special computers, cards and talking boards that can help.

Caring for the Person With Paralysis

People with paralysis can be helped with rehabilitation and restorative care with a physical therapist and/or an occupational therapist. More information about this care is below.

Caring for the Person With Headaches

Headaches can be treated with:

medicine,

stress management,

a quiet place, and

activities that divert the person from the headache and pain.

Restorative and Rehabilitation Care

A doctor writes an order for this treatment and care. After this, the physical therapist, occupational therapist and/or speech therapist see the patient or resident so that they can:

think about and find the best way to go about the care that the doctor has ordered and

decide on the goals of the care for the patient or resident.

The goals can include being able to:

eat on their own using special plates and utensils if needed,

get in and out of the bath tub or shower with a shower chair and grab rails if needed,

climb up stairs safely,

grab things,

have increased muscle strength, and

communicate with others with the spoken word.

Patients work with the healthcare team to decide on these goals. The person with a disability must be work to reach these goals on a daily basis. How well the person is reaching these goals is documented on a flow sheet, progress note or another tool, as used at your place of work.

Where is This Care Given?

This care can be given to the patient in the hospital, in the nursing home, in a group home, in a rehabilitation hospital, in an outpatient center and in the person's own home.

The place of care is based on the patient, their needs and the choices that there are in the area where the person lives.

Who Gives This Care?

Most of this care is provided by physical therapists, occupational therapists and speech therapists. Some rehab centers also have assistants and aides to help with this care. These people are given special training so that they are able to help the person to reach their goals.

The Role of Physical Therapy

Physical therapists give the person:

range of motion exercise,

muscle strengthening,

general conditioning exercises,

coordination exercises,

transfer training, and

ambulation help.

Range of Motion Exercise

Physical therapy provides range of motion exercise to help the person to move their joints fully after a long period of bed rest, or immobility, and when the person has a disorder like a brain injury. Pain and the lack of full movement occur when a joint does not have normal range of motion.

There are three (3) kinds of range of motion exercise. They are:

Active Range of Motion. Active range of motion is used when the person is able to do full range of motion to one or more parts of their body without the help of another. Nursing assistants and other members of the team may simply have to remind the person to do these exercises and to watch the person to make sure that they are doing them in the right way.

Active Assistive Range of Motion. This range of motion is used when a person needs some help doing full range of motion to one or more parts of the body because their muscles are too weak or stiff to do them on their own. The nursing assistant and other members of the team will have to help this person with their range of motion.

Passive Range of Motion. Passive range of motion is used for people who cannot move one or more parts of their body at all. The nursing assistant and other members of the team will have to do full range of motion for the person without any help from the patient.

Weights are sometimes used with active range of motion and active assistive range of motion.

Active assistive and passive range of motion exercises are done in a gentle, slow way so you do not hurt or harm the joints and bones. If the person gets pain, stop. These exercises are NOT done to the point of pain. They should also NOT be done to an area that has a broken bone that has not been taken care of.

Muscle Strengthening

These exercises are used for patients and residents of all ages.

The goal of these exercises may be to get the person strong enough to perform some basic activities of daily living, such as combing one's hair. These exercises help to bring weak muscles to their best possible strength. These exercises are also done with weights for some people.

General Conditioning Exercises

General conditioning exercises are done in order to:

increase the function of the heart and lungs,

to maintain range of motion and

to increase muscle strength.

Nursing assistants and other members of the team often help and/or remind the patient or resident to perform these exercises.

Coordination Exercises

These exercises are mostly used for patients that need help to use their hands or to walk with good balance and gait.

For example, a person that has had a brain injury may need these exercises in order for them to be able to pick up a spoon and place it in their mouth. Or, they may need these exercises so that they will be able to walk in a balanced and safe manner.

Transfer Training

This training helps people to be able to go safely from the bed to the chair, from the bed or chair to the toilet or from a sitting to a standing position. When a person is not able to do these transfers they must depend on others for help in this area.

The goal of this training is to help the person move about in a safe way without the help of others.

Ambulation Exercises

These exercises help the patient to walk safely without the help of another person. Some people may have to use a cane, splint, brace, crutches or a walker.

Some patients may have to have range of motion, balance, and muscle strengthening and/or coordination exercises before ambulation exercises can be started. At times a splint or brace may also be needed. Many people also practice with parallel bars, like the ones above, and/or a gait or ambulation belt.

Once the person is able to walk safely on a flat and level surface, they may then practice how to walk up and down stairs using a handrail. When a person walks up the stairs they should put their good leg up on the stair and then bring up the weak one.

Physical Therapy Treatments

Some of the treatments that physical therapist use are:

heat therapy,

cold therapy,

water therapy,

electrical nerve therapy,

traction, and

massage therapy.

Heat Therapy

Heat performs several roles. Heat:

increases the flow of blood to a body part,

helps to lower joint stiffness and pain,

decreases spasms of the muscles, and

stops swelling.

Heat therapy is often used for short term and chronic problems such as strains, sprains, spasms and neurological problems.

Heat can be given in one of two (2) ways:

Superficial

Deep

Superficial heat is given by using a heating pad, hot pack, a wax bath to a limb, like a hand, a warm water bath or whirlpool and with infrared heat using a lamp. Hot packs are used very often for heat therapy. When you apply a hot pack it must be wrapped in towels to protect the skin from a burn.

Deep heat is given with ultrasound and diathermy.

`Ultrasound is done with sound waves. These sound waves go deep into the body's tissues and it produces heat. This form of therapy is used when the patient has:

poor range of motion,

a muscle problem, and

back pain.

It is NOT used on areas that have dead tissue, such as a pressure sore or an area that is infected. It is also NOT used on eyes, ears, spinal cord, heart, brain or broken bones.

All heat must be given with great care. Heat can burn the skin of the person, especially when the patient or resident does not feel heat because of poor nerves and when they are not mentally able to tell a person that they feel the burn.

Cold Therapy

Sometimes cold is used right after an injury occurs. For example, the doctor may order cold for 48 or 72 hours after a person strains or sprains their ankle.

Cold performs the following roles. It:

decreases blood flow to the area and

stops swelling just after an injury has occurred.

Cold must also be given with care. It, too, can cause tissue damage (frost bite) and a lowered body temperature. Cold may be applied locally using an ice bag, a cold pack, or some fluids like ethyl chloride. Cold is NOT placed over areas of the body that do NOT have a good blood supply.

Water Therapy

Water therapy uses moving water to:

apply heat to an area,

help wound healing,

help with pain and to

relax the muscles.

This therapy is often used just before range of motion exercises so that the muscles are relaxed and the patient can be free of pain while going through range of motion.

Some water therapy is given using a Hubbard tank that is a very large whirlpool bath. The water is usually heated to from 96° to 104° F. Some patients and residents may feel weak and tired after water therapy so safety must be maintained. At times the person's blood pressure may drop while in the whirlpool

Electrical Nerve Stimulation

Muscles do NOT work in the correct way when nerves that contract muscles get damaged. Electrical nerve stimulation, using small electrodes, contracts these muscles to keep them from going into a spasm, something that often happens when a person has hemiplegia as the result of a brain injury. It also prevents muscles from shrinking, or atrophy, when they are not being used for one reason or another.

Some patients are given transcutaneous electrical nerve stimulation (TENS) by the physical therapist, according to the doctor's orders. The patient in their own home can even use this small machine after they, or a family member, is taught about how to use it. They are often used for back pain, arthritis, sprains and other disorders.

Traction

Traction is the use of a weight and pulley system to decrease muscle spasm and to keep bones in proper alignment. Traction can be used in all settings, including the home. Some traction is used on a continuous basis and other traction is used just for short periods of time.

Massage

Massage is also done by physical therapists. Massage helps to reduce pain and swelling. It is used for patients and residents that have a fracture, sprain, strain or nerve injury. Many people with low back pain, arthritis, bursitis, neuritis, hemiplegia, paraplegia, multiple sclerosis, and cerebral palsy are helped with massage.

The Role of Occupational Therapy

Occupational therapists, like physical therapists, are part of the rehabilitation and restorative care team. A patient's or resident's doctor writes an order for occupational therapy when the person can be helped in terms of their functioning, particularly in terms of performing the activities of daily living.

Some of the activities of daily living that the occupational therapist helps the person do are:

Dressing

Grooming

Mouth care

Bathing and/or showering

Feeding self

Cooking meals

Getting around and caring for the home

Some people need special assistive devices to do the activities of daily living. For example, a person may need special gripping devices to pick items up off the floor. Others may need special forks and eating utensils to better pick up food from their plate. Some may need special plates with high sides to hold food on the plate when a person has trouble with a spoon or a fork. Still others may need to have their clothing made with larger buttons or Velcro strips when they cannot dress using small buttons and zippers on their clothes.

Occupational therapists teach residents, patients and their family members how to use these special assistive devices so the person can be as independent as possible with the activities of daily living.

Nursing assistants should help their patients and residents with their activities of daily living, as planned by the occupational therapist and other members of the rehab team. For example, nursing assistants should help their patients and residents with dressing, brushing their teeth and using any special devices that they have.

The Role of Speech Therapy

Speech therapists help their patients with communication. They also help patients with a swallowing disorder, something that often happens after a stroke.

These therapists also use assistive devices. For example, they may use a word board so that a patient who cannot speak can communicate their needs to others.

Doctors write orders for speech therapy when the person is not able to talk with and communicate with others. Some of these patients or residents are not even able to make their own basic needs known to those that care for them. For example, a patient or resident knows that they are hungry or have to use the bathroom but they are not able to say it.

Nursing assistants should encourage the patient or resident to speak whenever this is possible. When the person cannot speak, the nursing assistant and other team members should give the patient or resident the communication tool that they have been given by the speech therapist. For example, if a person has a word board, encourage them to use it.

Some of the Devices Used for Restorative and Rehabilitation Care

Splints

Splints are specially made items for a patient or resident to prevent a deformity, such as a contracture, and to promote function. Some examples of splints are hand splints, a wrist splint and a foot drop splint.

Self-help Devices

Self-help devices help the patient or resident to be able to function in a safe way and independent way even though they have a disorder or a physical problem.

Some self-help devices are:

walkers,

canes,

shower chairs,

grab bars on the side and the back of the bathtub or toilet,

graspers or reachers to lift items up from the floor,

special eating utensils with built-up handles to help the person feed themselves,

special combs and brushes so that the person can groom themself,

shoehorns to help a person get dressed even though they do not have full range of motion,

raised sitting chairs, raised toilet seats, and chair leg extenders help people safely transfer without the help of another person and

cups with lids and special plates with deep centers and weight helps people eat their meal without spills.

Rehabilitation and restorative care play a very important part of healthcare.